Contraception 90 (2014) S22 – S31

Review article

Sexually transmitted infections: progress and challenges since the 1994

International Conference on Population and Development (ICPD)☆,☆☆,★
Nuriye Ortayli⁎, Karin Ringheim, Lynn Collins, Tim Sladden
330 East 38th Street, Apt 21B, New York, NY 10016, USA
Received 15 January 2014; revised 22 May 2014; accepted 10 June 2014

Abstract

Background: Despite being recognized as an important challenge at the 1994 International Conference on Population and Development
(ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health.
STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.
Progress since ICPD: During the last two decades, substantial knowledge and experience have accumulated in behavior change
programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in
development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a
rapid, point-of-care test for syphilis has opened the door to control this infection.
Challenges: The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995–2008. The growth in
STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and
gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of
surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as
an important public health problem; and failure to implement policies that are known to work.
Recommendations: Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully
implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing
in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of
microbial resistance.
© 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/3.0/).

Keywords: Policy; Women’s health; Reproductive health; Health services

1. Background and scope of the challenge

☆
This paper is not under consideration at any other journal. It is a
revised and shortened version of a background paper with the same title,
presented at the “ICPD Beyond 2014 Expert Group Meeting on Women’s
Health: Rights, Empowerment and Social Determinants” organized by
UNFPA-WHO in Mexico City during September 30–October 3, 2013.
☆☆
Authors have not received any financial compensation for writing this
paper, except that three of them are UNFPA staff, and one had been a
consultant for UNFPA in the team that wrote a report on ICPD progress.
None of the authors have any conflict of interest.
★
Authors would like to thank Ms. Adrienne Germaine and Dr. Rachel
Snow for reviewing earlier versions of the background paper and providing
valuable advice in strengthening it.
⁎ Corresponding author at: 330 East 38th Street, Apt 21B, New York,
NY 10016, USA. Tel.: +1 212 297 5001, +1 90 533 776 52 01.
E-mail addresses: ortayli@unfpa.org, nortayli@gmail.com (N. Ortayli).
The International Conference on Population and Devel-
opment (ICPD) in 1994 recognized the “high and increasing”
incidence of sexually transmitted infections (STIs) and,
particularly, the greater vulnerability to STIs that women
face, in part because such infections are often undetected
until complications ensue. The ICPD Programme of Action
(PoA) called for prevention and treatment of STIs to
“become integral components of all reproductive and sexual
health services” (Para 7.32). It further stipulated “that all …
family planning providers, should be given specialized
training in the prevention and detection of … sexually
transmitted diseases” (PoA 7.31) and provide “accessible,
complete and accurate information about various family

http://dx.doi.org/10.1016/j.contraception.2014.06.024
0010-7824/© 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/3.0/).
 N. Ortayli et al. / Contraception 90 (2014) S22–S31
planning methods, including … their effectiveness in the
prevention of the spread of HIV/AIDS and other sexually
transmitted diseases.” (PoA 723 b). Recognizing that the risk
of transmission is greater from men to women and that
women are often powerless to protect themselves (PoA
7.28), the ICPD urged the development of “strategies to
ensure that men share responsibility for sexual and
reproductive health, including family planning, and for
preventing and controlling STIs, HIV and AIDS.” (Para
8.27) [1]. However, the fight against STIs, other than HIV,
has been one of the least visible areas of sexual and
reproductive health (SRH), remaining underfunded despite
its close links to the HIV epidemic. A chief factor
contributing to this invisibility is a lack of national STI
surveillance systems capable of identifying the considerable
magnitude and scope of the problem, and monitoring
progress or lack thereof. Currently, only a small minority
of countries consistently collect STI surveillance data, and
even these are subject to limitations in data quality and
completeness [2]. Surveillance of antimicrobial resistance
within newly emerging gonococcal strains is similarly
lacking, with rates of multidrug-resistant gonorrhea increas-
ing worldwide and contributing to increases in gonorrhea
incidence. Enhanced surveillance is needed to track this
problem [3–5]. Furthermore, STI diagnoses often go
unreported due to weaknesses in health systems. The difficulty
of collecting reliable data on STIs is compounded by shortages
of trained human resources, inadequate laboratory facilities
and other constraints, such as asymptomatic presentation,
which together compromise accurate diagnosis. Owing to the
sexual nature of transmission, STIs are also often stigmatized,
and many individuals with symptoms do not seek testing or
treatment, while others receive inaccurate diagnoses. In the
absence of good surveillance data, there is a lack of public and
political awareness of the magnitude of the problem. STI
screening and treatment are not given priority within public
health services, nor do STIs receive the political, socioeco-
nomic and cultural attention they warrant.
In recent years, as new HIV infections were plateauing or
declining in many regions, the World Health Organization
(WHO) estimated that incidence of the four major curable
bacterial/protozoan STIs (chlamydia, gonorrhea, syphilis
and trichomonas) increased by nearly 50%. Using the limited
available data [6], WHO estimated the total number of new
Table 1
Estimated number of new cases of four bacterial STIs by WHO region (2008). 1
Numbers of new cases (millions).
Bacterial STI Africa Americas Southeast Asia
Chlamydia trachomatis 8.3 26.4 7.2
Neisseria gonorrhoeae 21.1 11.0 25.4
Treponema pallidum 3.4 2.8 3.0
Trichomonas vaginalis 59.7 85.4 42.9
Total 92.6 125.7 78.5
1
WHO. Global incidence and prevalence of selected curable sexually transmitted infections — 2008, 2012. Downloaded at http://www.who.int/
reproductivehealth/publications/rtis/stisestimates/en/index.html on May 21, 2013.
S23
infections with these four agents to have risen worldwide
from 333 million in 1995 [7] to 499 million in 2008 [2]. This
50% increase is only partially attributable to increased
population. For example, chlamydia has risen by nearly a
fifth, consistent with a 21% increase in global population over
that period, while gonorrhea rose by 70%. New syphilis
infections have slightly decreased, probably owing to
existing, extensive antenatal testing [2]. Regional differences
in STI incidence are widespread: e.g., Africa has the highest
number of new syphilis infections, probably related to limited
accessibility of care (Table 1 and Fig. 1). Higher levels of
untreated STIs in sub-Saharan Africa are linked to higher
HIV transmission rates and have been postulated to have
contributed to the higher prevalence of HIV in that region [8].
While developing country data are scarce, evidence from the
United States suggests that nearly half of STIs occur among
young people 15 to 24 years of age [9] (Fig. 2).
Viral STIs are incurable, and they also affect large
populations: an estimated 536 million people are living with
herpes simplex virus (HSV) type 2, and approximately 291
million women at any given time have a human papilloma virus
(HPV) infection [10]. Moreover, viral hepatitis, particularly
hepatitis B (HBV), can be sexually transmitted and is a growing
health concern, potentially leading to liver disease and cancer.
About 240 million people live with chronic HBV infection.
WHO identifies nine infections with a predominantly
sexual mode of transmission in the International Classifica-
tion of Diseases [11]. This paper focuses on the four
common curable bacterial/protozoan STIs that contribute to
most STI-related morbidity and mortality globally: chla-
mydia, gonorrhea, syphilis and trichomonas. While all STIs
have specific diagnostic tests and treatment regimens, many
preventative, management and surveillance aspects are
applicable more broadly for all STIs.
It is beyond the scope of this paper to address the HIV
epidemic in any significant depth, other than to highlight
some of the connections between HIV and other STIs,
particularly similar programming strategies. The response to
the HIV epidemic has been unparalleled, marked by
extraordinary activism, political commitment, resources
and significant gains in health and rights. Achievements
have been striking, particularly in the last decade, among
them a promising trajectory of considerably fewer new HIV
infections and AIDS-related deaths, and some notable but
Europe Eastern Mediterranean Western Pacific
20.6 3.2 40.0
3.4 3.1 42.0
0.2 0.6 0.5
22.6 20.2 45.7
46.8 26.4 128.2
S24 N. Ortayli et al. / Contraception 90 (2014) S22–S31
7.0

6.0

5.0

4.0

Percent
3.0

2.0

1.0

-
Africa Americas South-East Asia Europe Eastern Western Pacific World
Mediterranean
Chlamydia Gonorrhoea Syphilis Trichomonas

STI data: http://apps.who.int/iris/bitstream/10665/75181/1/9789241503839_eng.pdf; Population Data: www.who.int/whosis/whostat/2010/en/

Fig. 1. Estimated total population prevalence (%) of bacterial STIs, WHO Health Regions, 2008. 2

Fig. 2. Chlamydia—rates by age and sex, United States, 2011. 3

precarious gains in human rights. While new HIV infections
have steadily declined since the peak in 1997, the increased
availability of life-extending antiretroviral treatment has led
to an increase, to 34 million, in the number of people living
with HIV globally [12]. HIV is the fifth most common cause
of death for adults and a leading cause of death in women of
reproductive age [13].
Global HIV prevalence today, among adults 15 to
49 years old, is 0.8% and is below 1% in all regions, except
sub-Saharan Africa, where prevalence is 4.7%. In this most
severely affected region, 57% of 22 million persons living
with HIV over age 15 are women [12]. As with other STIs,
biological factors, gender-based violence, sexual coercion
and lack of access to information and services are among
the key factors that promote increased vulnerability of
women and girls to HIV [12]. HIV is the only STI for
which functioning surveillance systems are generally in
place. The relative success of HIV surveillance demon-
strates that with political commitment, adequate resources
and a rapid point-of-care test appropriate for low-resource
2
WHO. Global incidence and prevalence of selected curable sexually
transmitted infections — 2008, 2012. Downloaded at http://www.who.int/
reproductivehealth/publications/rtis/stisestimates/en/index.html on May 21,
2013.
3
Downloaded from: http://www.cdc.gov/std/stats11/figures/5.htm on
May 30, 2013.
 N. Ortayli et al. / Contraception 90 (2014) S22–S31
settings, surveillance systems for other STIs are feasible for
many low-income countries.
1.1. STIs can lead to serious health problems for women
STIs and complications resulting from them are among the
top five reasons that adults seek health care [14]. Aside from
HIV, other STIs may also pose serious reproductive health
concerns for women and their infants. STIs, principally
untreated chlamydia, are the major underlying cause of
infertility among women. Up to 40% of women with untreated
chlamydia or gonorrhea will develop pelvic inflammatory
disease (PID), and one in four of these women will become
infertile. Women with PID are also 6 to 10 times more likely to
have an ectopic pregnancy, putting women’s lives at risk and
inevitably leading to fetal loss. Up to half of such ectopic
pregnancies are the result of a previous PID. Women with
untreated syphilis have a 25% probability of stillbirth and a
14% probability of neonatal death. It is estimated that,
globally, up to 4000 newborn babies become blind every
year because of eye infections attributable to untreated
maternal gonococcal and chlamydial infections [15].
In 2008, an estimated 1.4 million pregnant women around
the world were infected with syphilis, 80% of whom had
attended antenatal care services. Syphilis infections among
pregnant women caused approximately 520,000 harmful
outcomes, including 215,000 stillbirths, 90,000 neonatal
deaths, 65,000 preterm or low-birth-weight babies and
150,000 congenital infections. Two thirds of these adverse
outcomes occurred among women who were neither tested
nor treated for syphilis despite an antenatal care visit [16].
STIs also significantly increase the risk of both acquiring
and transmitting HIV. Genital ulcers are estimated to cause a
50- to 300-fold increased risk of acquiring HIV per episode
of unprotected sex [15]. Even nonulcerative STIs increase
the likelihood of HIV transmission. Overall, improving
the management of STIs is an important strategy in
HIV prevention.
2. Interventions to control STIs/HIV
STIs, including HIV, are caused by microorganisms, and
their acquisition is often closely linked to certain behaviors.
“[Sexual] partnership and network formation, and the chance
of acquiring and transmitting an infection sexually are not
random; they are determined by individual factors, cultural
values, geography, demography, economics, heath service
and political and legal structures.” [17]. STIs spread most
easily when individuals, especially women, have little power
to negotiate safer sex and have poor access to health services.
Effective STI prevention and control require coordinated
efforts to address those factors that facilitate transmission or
that hamper access to prevention, detection, diagnosis and
treatment. Such strategies include promoting and supporting
community-led interventions, eliminating stigma and gen-
der-based violence, providing clinical services that respect
S25
confidentiality, and improving collection and use of reliable
data to guide evidence-informed responses. The epidemio-
logical approach suggests concentrating efforts on high-risk
groups such as sex workers and their clients to more rapidly
control the spread of STIs [18], whereas the ICPD PoA
promotes a broader focus on ensuring universal access to STI
services as part of comprehensive sexual and reproductive
health care. Given the numerous factors that have an impact
on transmission or control of STIs, programs should
harmonize several interventions. All programs should have
a strategy that would include the following [19];
1. Primary prevention which includes health promotion
and education, school- and community-based pro-
grams, and male and female condom distribution
2. Diagnosis and management of infections, which will
build on primary prevention and add diagnostic
services, clinical services, and patient and partner
management services. Each of these elements should
be evidence based and adapted to the national/
subnational context.
3. Opportunistic testing or screening for asymptomatic cases.
2.1. Primary prevention
2.1.1. Behavioral approaches
Several behaviors decrease the incidence of STIs and HIV
including delaying sexual debut, using condoms and having
fewer sexual partners [20]. Related behavior change
interventions aim to change social norms and build the
knowledge, motivation and especially skills to support safer
sexual practices. Behavioral risk reduction programs use
counseling, information and empowerment techniques to
build motivation and capacity to practice safer sex and
change social norms. They enhance decision-making ability
for reducing risk of exposure and transmission within sexual
relationships, including condom negotiation and use. Best
described in the HIV literature, “combination prevention,”
comprised of behavioral, biomedical and structural inter-
ventions, has had demonstrated results for HIV, which are
also applicable for preventing STIs [20,21]. Key behavioral
programs include testing and risk reduction counseling,
behavior change communication, comprehensive sexuality
education, media and interpersonal communication (includ-
ing peer education), social marketing of male and female
condoms, and incentives for avoiding risk.
Globally, since 2000, there has been a steady upturn in the
practice of safer sex in most countries, which is having a
favorable impact on the downward trend in new HIV
infections [22]. A recent meta-analysis of 42 studies,
covering 67 behavioral interventions, indicated an associated
decrease in sexual risk-taking resulting in increased condom
use, and fewer STIs, including HIV [23]. Many countries,
including Kenya, Malawi, South Africa, Tanzania, Trinidad,
Zambia and Zimbabwe, are reporting favorable results from
behavioral interventions [24–27]. Comprehensive sexuality
education is indispensable for behavior change and has been
S26 N. Ortayli et al. / Contraception 90 (2014) S22–S31
demonstrated to increase knowledge and decrease risk-
taking [28]. A review of 83 studies worldwide showed that
two thirds of the sex and HIV education programs improved
one or more sexual behaviors in young people [29].
Behavioral interventions can have an appreciable impact
when combined with other approaches and implemented at
scale [21]. It is, however, difficult to disentangle the relative
impact and attribution of these factors, but together these
combined approaches hold the key to effective HIV/STI
prevention. These interventions need to be brought to scale
and sustained to have impact within populations at risk [30].
Moreover, behavioral interventions should be coupled with
structural approaches to eliminate gender-based violence,
child marriage and other human rights violations, which
contribute to risk of HIV and STI exposure and transmission.
2.1.2. Biomedical approaches
Improved use of condoms, together with risk reduction
counseling, is a priority STI control intervention [31]. Male
and female condoms not only are effective in protecting
against transmission of HIV but also significantly reduce the
risk of acquiring several other STIs such as gonorrhea,
chlamydia, HSV-2 and syphilis. Condoms also reduce the
risk of trichomoniasis [32] and may provide some protection
from HPV transmission [33]. Generating greater demand for
male and female condoms among specific clients at higher
risk of STIs, including youth, has yielded positive results
when policies and policy makers are consistently supportive,
myths and misperceptions about condoms have been
addressed, condom negotiation skills and correct use are
widely taught, and adequate supplies of quality male and
female condoms are distributed free or at an affordable price
through multiple channels [34].
Condom supplies in many high-burden countries are still
inadequate: 2011 estimates for Sub-Saharan Africa indicate
that only nine donor-provided condoms per year are
available for each 15–49-year-old man and that only one
female condom per year is available for every 10 women of
the same age range. Numerous countries are now engaged in
implementing comprehensive condom programming
through a strategic 10-step approach that addresses coordi-
nation, supply, demand and support [35].
Male and female condoms can also be used for protection
against unintended pregnancies, but male condoms have a
contraceptive failure rate of 18% in the first year of typical
use [36]. Therefore, “dual protection,” where condoms are
used together with a modern contraceptive which is highly
effective in preventing pregnancy, is an essential strategy for
ensuring protection against both HIV/STIs and pregnancy.
Though there has been an increase in dual-method use
especially among at-risk populations, there is still much
room for improvement [37–39].
Since ICPD, there have been efforts to develop
multipurpose prevention technologies (MPTs) for SRH to
simultaneously address diverse needs for combinations of
STI, HIV and pregnancy prevention. Currently, the only
available MPT is the female or male condom. However,
several other MPTs that could address two or more
prevention needs at the same time are in the pipeline.
Some of these include an intravaginal ring that continuously
releases tenofovir and levonorgestrel from separate ring
segments over a period of 90 days for contraception and HIV
prevention; a gel combining MIV-150, zinc acetate and
carrageenan, with combined activity against HIV and HSV;
and a vaginal ring releasing dapivirine and a hormonal
contraceptive over 60 days for contraception and HIV
prevention. Reformulated tenofovir gel is also being studied
in conjunction with the existing SILCS diaphragm as a
combined barrier contraceptive, adding sperm-immobilizing
agents and antiviral chemical protection against HIV and
HSV [40].
As with the majority of infectious diseases, use of
vaccines can be a turning point in controlling STIs.
Currently, for two STIs, HBV and HPV, there are safe and
effective vaccines. HBV vaccine is now adopted by more
than 90% of countries and is part of childhood immunization
programs [10].
The two types of HPV vaccines that are available now are
both highly efficacious in preventing infection with virus
types 16 and 18 that together are responsible for causing
approximately 70% of cervical cancer cases globally. One
vaccine is also highly efficacious in preventing anogenital
warts, a common genital disease which is virtually always
caused by infection with HPV types 6 and 11. Recently, use
of the HPV vaccine by both girls and boys was approved in a
number of industrialized countries, 4 yet the primary target
group continues to be young adolescent girls in the
remaining countries as recommended by WHO [41].
The high cost discouraged many countries with a high
burden of disease from introducing the vaccine at national
scale, until recently. With a lower public sector price and the
backing of the GAVI Alliance (formerly the Global Alliance
for Vaccines and Immunization), the vaccines can become
much more widely available [42]. WHO estimates that, with
70% vaccination coverage, current vaccines can prevent 4
million cervical cancer deaths over the next decade [10].
2.1.3. Services for diagnosis and management
Diagnosis and management of STIs present many chal-
lenges, depending on the characteristics of different agents.
Diagnosis of gonorrhea and chlamydia is especially challeng-
ing for several reasons. Firstly, up to 70% of women, and a
significant proportion of men, with either gonorrhea or
chlamydia experience no symptoms until complications
develop. Because women’s infections are more often unde-
tected due to their asymptomatic nature and since women often
have less access than men to STI testing and treatment, women
have far greater STI-related morbidity than men [43].
4
Recently, CDC USA has recommended HPV vaccine also for
adolescent boys. http://www.cdc.gov/hpv/vaccine.html.
 N. Ortayli et al. / Contraception 90 (2014) S22–S31 S27

Table 2 risk of having an STI are limited by the unreliability of self-

Sensitivity, specificity [43] and price 5 of rapid chlamydia, gonorrhea, reporting, especially in low-prevalence settings [50].
syphilis and trichomonas tests.
Assuming needed medications are available, compliance
Organism Test Sensitivity Specificity Price with the treatment regimen is important to its success as well
Chlamydia ICT 33%–95% N95% High as to preventing the development of multidrug resistance.
OIA Breaking the chain of STI transmission requires preventing
Chlamydia NAAT 97%–99% 99%–100% High
reinfection and onward transmission to other sexual partners.
Gonorrhea ICT, OIA 54%–70% 90%–98% High
Gonorrhea NAAT 96%–100% 100% High Providing earlier “treatment for prevention” has the potential
Syphilis ICT strip 86% (median) 99% (median) Very low to significantly lessen infectivity and decrease transmission
b $1 to uninfected partner(s) [51]. Counseling on consistent
Trichomonas Wet mount 50%–54% N95% Very low condom use also aims to prevent transmission to partners
Trichomonas OSOM® 83%–90% 98%–100% High
or reinfection by partners. Partner notification is a key
Rapid test
strategy to reach the presenting client’s sexual partner(s),
ICT, ımmunochromatographic; OIA, optical ımmunoassay; NAAT, nucleic who may themselves be asymptomatic. If left untreated,
acid amplification tests.
5
Price information is collected by UNFPA.
partner(s) may suffer serious health consequences, may
reinfect the treated partner and may transmit to other
partners. Partners can be notified by the health provider or
Secondly, tests for diagnosing chlamydia and gonorrhea the client. One approach, sometimes referred to as expedited
infections not only are expensive but also require sophisti- partner therapy, involves providing the client the requisite
cated laboratory facilities and highly trained staff, making it medication or prescription to deliver to their partner(s), with
very difficult to offer these tests in low-resource settings. instructions for use [15]. This obviates the need for the
Among the four bacterial/protozoan STIs, currently, only partner(s) to come to the clinic and can increase the potential
syphilis has an inexpensive, rapid, point-of-care test that can for partner treatment. Because partner notification can lead to
be used in low-resource settings and can accurately intimate partner violence and other relationship problems,
determine the existence or absence of infection, meeting client safety must be carefully considered, especially when
WHO’s Affordable, Sensitive, Specific, User-friendly, notification is based on potentially inaccurate syndromic
Rapid and robust, Equipment-free and Deliverable to end diagnosis of infection among women [17].
users (ASSURED) criteria for low-resource settings [44].
Trichomonas protozoan infection can be detected by 2.1.4. Screening
collecting a specimen during speculum examination and Many people who acquire an STI do not have symptoms,
identifying it under a microscope, and there is hope for or symptoms are mild and may disappear while the infection
development of new tests meeting ASSURED criteria remains. Therefore, any efforts to determine the true extent
[45]. (Table 2). of STIs within the population or to control STIs require the
Thirdly, although syndromic management is recommend- ability to diagnose asymptomatic infections as well as those
ed by WHO for use in settings where etiologic diagnosis is that are symptomatic. Several tests with high sensitivity and
not possible, it is neither very sensitive (accurate in specificity are available to diagnose certain specific STIs,
confirming an STI) nor specific (correctly ruling out both symptomatic and asymptomatic.
infection), especially for common syndromes like vaginal
discharge among women. Syndromic management relies on 2.1.5. Chlamydia and gonorrhea
simple flowcharts to help health care workers identify easily Screening to identify and treat chlamydia among asymp-
recognizable signs (syndromes) and provides an algorithm to tomatic women has been shown to reduce complications and
guide treatment of the most probable cause(s). Treating the transmission of the infection [52,53]. However, only a handful
client at the first visit helps prevent complications and loss to of countries either offer opportunistic testing of certain subsets
follow-up and provides an opportunity for client education, of women, such as those seeking contraceptive or abortion
counseling on safer sexual behavior, promotion or provision services, or have programs which aim to screen all younger
of condoms, partner notification, and HIV testing women (below the age of 25 or 29, age varying from country to
and counseling. country) [19,54–56]. Sweden’s opportunistic chlamydia
The syndromic approach, however, can overdiagnose testing is an example which revealed success as well as new
STIs, exposing women to unnecessary treatment [46] and to challenges. Opportunistic testing for chlamydia among young
possible risks, including relationship problems and even women in a variety of health care settings was introduced in
violence, if partners are given a false alert. It can also fail, as some counties in Sweden in the early 1980s (Fig. 3). Since
shown by several studies, to diagnose existing infections 1988, the law has made it compulsory across the country to
[47–49]. This is especially significant given the serious provide free testing, treatment and contact tracing for any user
health consequences for women and infants caused by of services with suspected chlamydia and to report diagnosed
untreated chlamydia and gonorrhea. Efforts to increase the infections. Testing is targeted at sexually active women aged
effectiveness of the syndromic approach by assessing the 15–29 years seeking contraception or abortion. Men are tested
S28 N. Ortayli et al. / Contraception 90 (2014) S22–S31
Fig. 3. Rates of reported genital chlamydia infection in selected countries,
1989–2003. 6
when found through contact tracing or if symptomatic. Youth
clinics have been established in many places to increase access
to services for young people, including young men. As a result,
the number of chlamydia infections decreased dramatically
during the 1990s (Fig. 3). However, in 2007, a new chlamydia
variant which could not be identified with the tests used at the
time again caused an increase in infections [57]. This
development of a new strain of chlamydia illustrates the
importance of surveillance to track STI-causing organisms and
their susceptibility to treatment. Sweden also participates in an
ongoing multicountry European gonococcal antimicrobial
susceptibility surveillance study, which has documented
growing resistance to the primary drugs for treating gonorrhea,
suggesting that gonorrhea may become untreatable using
antimicrobial monotherapy [4].
2.1.6. An example of opportunistic testing: antenatal
screening for syphilis
Syphilis, unlike many other STIs, has an inexpensive,
rapid, point-of-care test, which can be used in low-resource
settings, produces results within 20 min and confirms the
presence of infection with high sensitivity and specificity
(Table 2). Treatment of syphilis is also easy and inexpensive.
A systematic review has found that opportunistic testing of
all pregnant women who use antenatal care services for
syphilis and their treatment could reduce the incidence of
perinatal death and stillbirth attributable to syphilis by 50%,
saving about 200,000 lives per year [58]. Most countries
have policies for antenatal screening of STIs and HIV, but
implementation is uneven. In some countries, for example,
programs specifically designed to prevent new HIV
infections in infants, including by preventing HIV infection
in pregnant women and by screening and treating them for
HIV [59], did not include similarly aggressive syphilis
screening [60], despite it being part of the recommended
global strategy [61]. This is a missed opportunity which is
6
Low N. Current status of chlamydia screening in Europe. Euro
Surveill. 2004;8(41):pii = 2566.
currently being more vigorously addressed. Lack of
universal access to antenatal care and attrition rates also
limit the success of screening programs. The most recent data
show that an estimated one in five pregnant women with
syphilis did not receive antenatal care [16].
3. Policies
3.1. Integration of SRH services, including HIV and STIs
Integrating STIs/HIV with other SRH programs involves
delivering a wide range of interventions to meet the
comprehensive needs of clients such as offering rights-
based family planning services to women living with HIV,
delivering comprehensive sexuality education for young
boys and girls, preventing child marriage, eliminating
gender-based violence, managing sexually transmitted
infections, ensuring access to female and male condoms
for dual protection (against HIV/STIs and unintended
pregnancy) and providing antiretroviral treatment as well
as cervical cancer screening.
However, in responding to the AIDS crisis, key decisions
made by global organizations and major donors led to the
widespread development of stand-alone HIV services. STI
programming was integrated neither into these HIV services
nor into “its logical programmatic base[s] in sexual and
reproductive health and rights.” [62]. Separate “vertical”
health programs have resulted in lost opportunities for
offering clients multiple services at a single visit. STI
programs were not given high priority, and efforts to prevent
HIV transmission were “largely managed through programs
that [were] funded, implemented and evaluated indepen-
dently of other STI control efforts.” [18].
Integrating STIs/HIV with other SRH programs, such as
family planning and maternal health, can better meet the
comprehensive needs of clients, ideally bringing all services
together in one place and time. A global movement began in
2004 to link HIV and all SRH services, including STIs, at
policy, systems and service delivery levels [63]. In 2009, the
Commission on Population and Development urged gov-
ernments to expand the capacity to deliver comprehensive
HIV interventions in ways that strengthen national health
and social systems by integrating them into primary health
care, as well as by integrating SRH information and services,
including for STIs, into HIV plans and strategies [64].
The evidence base has been growing on how integration
strengthens health systems’ ability to offer clients compre-
hensive services and how such services can optimally be
integrated. Systematic reviews of integrated service delivery
have found a positive impact on client satisfaction, improved
access to and uptake of services without a reduction in
quality, favorable health and behavioral outcomes, reduced
clinic-based STI/HIV-related stigma and cost-effectiveness
[65,66]. Much more remains to be done to fully integrate STI
services within broader SRH and HIV programs and to better
deliver STI services within primary health care settings.
 N. Ortayli et al. / Contraception 90 (2014) S22–S31
3.2. Reaching key populations
Sex workers, their clients and other partners, men who
have sex with men and transgender people, and people who
inject drugs have a higher likelihood of contracting an STI.
However, due to marginalization, criminalization and
cultural attitudes, the access to health service for these key
populations is frequently lower than that for others. There is
now good evidence for what works for specific key
population groups [67–69]. Tailoring services for key
populations, including reducing stigma and discrimination,
is important to ensure uptake, and efforts are needed to try to
ensure universal access for these higher-risk populations.
Better linkage and integration of STI services within these
focused programs, as well as within a broader range of SRH
services for the whole community, are among the important
factors to be considered in the future direction of STI
prevention and control efforts.
4. Recommendations
4.1. Strengthening health systems
Integrating comprehensive SRH services, including for
STIs, within primary health care is a core element. STI
prevention and control require a strong health system which
can deliver all aspects of STI management in a coordinated
way (e.g., counseling, screening, diagnosis, treatment, follow-
up and partner notification). All SRH services, including
family planning, should take into account the risk for STIs and
HIV when providing information, treatment and contraceptive
choices. All clients should be instructed on the importance of
consistent condom use for HIV and STI prevention and on
how to negotiate their use. Female and male condoms should
also be made widely available. Concerted efforts are needed to
ensure that all pregnant women receive ANC early in
pregnancy and that screening and treatment for syphilis are
standard components of such care.
4.2. Behavior change interventions
All sexually active women and girls should have, at a
minimum, access to information on the risks and symptoms of
STIs, including an assessment of their own vulnerability, and
how to reduce risk. Community-led interventions are needed
to provide information on STIs, prevention education,
unlimited access to male and female condoms, and referral
for diagnosis and treatment, especially in low-resource areas
lacking access to comprehensive primary health care.
Community advocacy and education should engage men in
protecting women and children from the health risks of STIs
through promoting safer sex practices, access to treatment,
preventing and addressing gender-based violence and assuring
the safety of women in partner notification. The needs of
specific key populations need to be addressed through current,
identified best practice approaches.
S29
4.2.1. A focus on young people to reduce vulnerability
Adolescents, especially girls, need universal access to
SRH services, including HIV and STI screening, counseling
and treatment or referral. These comprehensive services need
to be respectful of their right to privacy, to confidentiality
and to make their own decisions free from coercion.
Comprehensive sexuality education including in schools
can play a much greater role in educating youth about the
health risks of asymptomatic and symptomatic infections for
both adolescent boys and girls. Such programs should help
girls develop the skills needed to combat the gender and
social factors that render women and girls vulnerable to
infection, support skills-building for negotiation and use of
female and male condoms, and instill an understanding of the
potential benefits of treatment for one’s own health and as
prevention of transmission.
4.3. Better diagnostics, vaccines and treatments
Inexpensive and accurate rapid point-of care diagnostic
tests, especially for chlamydia and gonorrhea, are urgently
needed in low-resource settings which lack laboratory facilities.
Increased investment in research to develop rapid tests and
address the high and growing rate of antimicrobial resistance is
needed, as well as accelerated research on vaccines. A high
priority should be placed on developing MPTs.
4.4. Increased STI surveillance
Global understanding of STIs and the disease burden they
cause suffers from a lack of data. To better understand the
epidemic and tailor programs effectively, greater investment
is needed to improve STI surveillance and consistent
reporting of known infections; follow up on partner
notification; and collect and report data separately for men
and women on the duration of infection, asymptomatic
infections, antimicrobial resistance patterns, etc. Surveil-
lance of STIs among women, especially of gonorrhea and
chlamydia, should not be neglected because of the lack of
rapid diagnostics. Existing diagnostics should be made
available in all countries, at least for the purpose
of surveillance.
This paper examines the current status of interventions
and responses to the growing and neglected global epidemics
of sexually transmitted infections other than HIV. While
many challenges exist, there are also opportunities to better
apply evidence-informed and human-rights-based ap-
proaches for control of STIs.
References
[1] UNFPA. International Conference on Population and Development–
ICPD — Programme of Action. Available from http://www.unfpa.org/
webdav/site/global/shared/documents/publications/2004/icpd_eng.pdf
[on May 21, 2003].
[2] WHO. Global incidence and prevalence of selected curable sexually
transmitted infections — 2008, 2012. Available from http://www.
S30 N. Ortayli et al. / Contraception 90 (2014) S22–S31
who.int/reproductivehealth/publications/rtis/stisestimates/en/index.
html [on May 21, 2013].
[3] Ohnishi M, Golparian D, Shimuta K, et al. Is Neisseria gonorrhoeae
initiating a future era of untreatable gonorrhea? Detailed characteri-
zation of the first strain with high-level resistance to ceftriaxone.
Antimicrob Agents Chemother 2011;55(7):3538–45, http://dx.doi.org/
10.1128/AAC.00325-11 [PMid:21576437 PMCid:3122416].
[4] European Centre for Disease Control. Gonococcal antimicrobial
susceptibility surveillance in Europe, 2011978-92-9193-450-8; 2013
[Stockholm].
[5] U.S. Department of Health and Human Services. CDC sexually
transmitted disease surveillance 2012: Gonococcal Isolate Surveillance
Project (GISP) supplement and profiles; 2014 [Atlanta. Available from
http://www.cdc.gov/std/gisp (accessed 14 March 2014)].
[6] WHO estimates for chlamydia, gonorrhea, and syphilis in North
America and for syphilis in WHO Euro are based on surveillance data.
For other regions and infections prevalence, estimates were generated
from prevalence data.
[7] WHO. Global prevalence and incidence of selected curable sexually
transmitted infections. available from http://www.who.int/hiv/pub/sti/
who_hiv_aids_2001.02.pdf [on May 21,201].
[8] Johnson LF, Dorrington RE, Bradshaw D, Coetzee DJ. The role of
sexually transmitted infections in the evolution of a South African HIV
epidemic. Trop Med Int Health 2012;17(2):161–8, http://dx.doi.org/
10.1111/j.1365-3156.2011.02906.x [Epub 2011 Oct 31. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/22035250].
[9] Weinstock H, Berman S, Cates W. Sexually transmitted diseases
among American youth, incidence and prevalence estimates, 2000.
Perspect Sex Reprod Health 2004;36:6–0.
[10] World Health Organization. Sexually transmitted infections.
Available from http://apps.who.int/iris/bitstream/10665/82207/1/
WHO_RHR_13.02_eng.pdf2013.
[11] World Health Organization. International statistical classification of
diseases and related health problems 10th revision (ICD-10) version
for 2010. Available from http://apps.who.int/classifications/icd10/
browse/2010/en#/A50-A64 [on March 25, 2014].
[12] UNAIDS. Global report UNAIDS report on the global AIDS epidemic.
Geneva: UNAIDS; 2012. [Available from http://www.unaids.org/en/
media/unaids/contentassets/documents/epidemiology/2012/gr2012/
2012_FS_regional_ssa_en.pdf June 6, 2013].
[13] Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality
from 235 causes of death for 20 age groups in 1990 and 2010: a
systematic analysis for the Global Burden of Disease Study 2010.
Lancet 2012;380(9859):2095–128.
[14] WHO. Sexually transmitted infections. Fact sheet no. 110. Updated on
May 2013, available from http://www.who.int/mediacentre/factsheets/
fs110/en/index.html2013.
[15] WHO. Global strategy for the prevention and control of sexually
transmitted infections, breaking the chain of transmission. Geneva:
WHO; 2006–2015. 2007.
[16] Newman L, Kamb M, Hawkes S, Gomez G, Say L, Seuc A, et al.
Global estimates of syphilis in pregnancy and associated adverse
outcomes: analysis of multinational antenatal surveillance data. PLoS
Med 2013 [Available from http://www.plosmedicine.org/article/info%
3Adoi%2F10.1371%2Fjournal.pmed.1001396 on May 21, 2013].
[17] Low N, Broutet N, Adu-Sarkodie Y, Barton P, Hossain M, Hawkes S.
Global control of sexually transmitted infections. Lancet 2006;368
(9551):2001–16.
[18] Steen R, Wi TE, Kamali A, Ndowa F. Control of sexually transmitted
infections and prevention of HIV transmission: mending a fractured
paradigm. Bull World Health Organ 2009;87:858–65.
[19] European Centre for Disease Control. Chlamydia control in Europe,
2009. Available from http://www.ecdc.europa.eu/en/publications/
publications/0906_gui_chlamydia_control_in_europe.pdf2014.
[20] UNAIDS. UNAIDS thematic segment background paper. Combina-
tion prevention: addressing the urgent need to reinvigorate HIV
prevention responses globally by scaling up and achieving synergies to
halt and begin to reverse the spread of the AIDS epidemic; 2012.
[Geneva, Switzerland. 5-7 June 2012 Available from http://www.
unaids.org/en/media/unaids/contentassets/documents/pcb/2012/
20120516_ThematicSegment_background_paper_en.pdf].
[21] UNAIDS. Combination HIV prevention: tailoring and coordinating
biomedical, behavioral and structural strategies to reduce new HIV
infections. A UNAIDS discussion paper. UNAIDS; 2010. [JC2007].
[22] UNAIDS. Global report UNAIDS report on the global AIDS epidemic
2013. Geneva: UNAIDS; 2013. [http://www.unaids.org/en/media/
unaids/contentassets/documents/epidemiology/2013/gr2013/
UNAIDS_Global_Report_2013_en.pdf].
[23] Scott-Sheldon LAJ, Huedo-Medina TB, Warren MR, Johnson BT,
Carey MP. Efficacy of behavioral interventions to increase condom use
and reduce sexually transmitted infections: a meta-analysis, 1991 to
2010. J Acquir Immune Defic Syndr 2011;58:489–98.
[24] Bello G, Simwaka B, Ndhlovu T, Salaniponi F, Hallett TB. Evidence
for changes in behavior leading to reductions in HIV prevalence in
urban Malawi. Sex Transm Infect 2011;87(4):296–300.
[25] Gregson S, Gonese E, Hallett TB, Taruberekera N, Hargrove JW,
Lopman B, et al. HIV decline in Zimbabwe due to reductions in risky
sex? Evidence from a comprehensive epidemiological review. Int J
Epidemiol 2010;39(5):1311–23.
[26] Johnson LF, Hallett TB, Dorrington RE. The effect of changes in
condom usage and antiretroviral treatment coverage on human
immunodeficiency virus incidence in South Africa: a model-based
analysis. J R Soc Interface 2012;9(72):1544–54.
[27] Burton J, Darbes LA, Operario D. Couples-focused behavioral
interventions for prevention of HIV: systematic review of the state
of evidence. AIDS Behav 2010;14:1–0.
[28] UNESCO. International technical guidance on sexuality education.
Geneva: UNESCO; 2009.
[29] Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs:
their impact on sexual behaviors of young people throughout the world
review article. J Adolesc Health 2007;2007(40):206–17.
[30] Gurman T, Rubin S, Roess A. Effectiveness of mHealth behavior
change communication interventions in developing countries: a
systematic review of the literature. J Health Commun 2012;17
(Suppl 1):82–04, http://dx.doi.org/10.1080/10810730.2011.649160.
[31] Manhart LE, Holmes KK. Randomized controlled trials of individual-
level, population-level, and multilevel interventions for preventing
sexually transmitted infections: what has worked? J Infect Dis
2005;191(Suppl 1):S7–24.
[32] Gallo MF, Steiner JF, Warner L, et al. Self-reported condom use is
associated with reduced risk of chlamydia, gonorrhea and
trichomoniasis. Sex Transm Dis 2007;6(34):829–33 [Center for
Disease Control, Condoms and STDs: fact sheet for public health
personnel. Available from www.cdc.gov/condomeffectiveness/
latex.htm].
[33] Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing
sexually transmitted infections. Bull WHO 2004;82:454–61.
[34] Haddock S, Hardee K, Gay J, et al. Comprehensive HIV prevention:
condoms and contraceptives count. Washington DC: Population
Action International; 2008.
[35] UNFPA, UNFPA. Comprehensive condom programming. Available
from http://www.unfpa.org/webdav/site/global/shared/documents/
publications/2011/CCP.pdf [on July 21, 2013].
[36] Trussell J. Contraceptive failure in the United States. Contraception
2011;83(5):397–404.
[37] Yam EA, Mnisi Z, Mabuza X, Kennedy C, Kerrigan D, Tsui A, et al.
Use of dual protection among female sex workers in Swaziland. Int
Perspect Sex Reprod Health 2013 Jun;39(2):69–78, http://dx.doi.org/
10.1363/3906913.
[38] Seutlwadi L, Peltzer K. The use of dual or two methods for
pregnancy and HIV prevention amongst 18–24-year-olds in a cross-
sectional study conducted in South Africa. Contraception 2013;87
(6):782–9, http://dx.doi.org/10.1016/j.contraception.2012.09.026
[Epub 2012 Oct 31].
 N. Ortayli et al. / Contraception 90 (2014) S22–S31
[39] Higgins JA, Cooper AD. Dual use of condoms and contraceptives in the
USA. Sex Health 2012;9(1):73–80, http://dx.doi.org/10.1071/SH11004.
[40] Harrison PF, Hemmerling A, Romano J, Whaley KJ, Young Holt B.
Developing multipurpose reproductive health technologies: an inte-
grated strategy. AIDS Res Treat 2013:15, http://dx.doi.org/10.1155/
2013/790154 [Article ID 790154].
[41] WHO. Immunization, vaccines and biomedicals: human papilloma
virus. Available from, http://www.who.int/immunization/topics/
hpv/en/ [on March 12. 2014].
[42] GAVI. GAVI welcomes lower prices for life-saving vaccines. Geneva:
Press Release; 2011 [Available from, http://www.gavialliance.org/
library/news/press-releases/2011/gavi-welcomes-lower-prices-for-
life-saving-vaccines on August 20, 2013].
[43] Abouzahr C. Trends and projections in mortality and morbidity. Paper
prepared for UNFPA–WHO meeting “ICPD Beyond 2014 Expert
Group Meeting on Women’s Health: Rights, Empowerment and Social
Determinants”. September 30–October 3, 2013, Mexico City; 2013.
[44] Peeling RW, Holmes KK, Mabey D, Ronal A. Rapid tests for sexually
transmitted infections (STIs): the way forward. Sex Transm Infect
2006;82(Suppl V):v1–6, http://dx.doi.org/10.1136/sti.2006.024265.
[45] Gaydos C, Hardick J. Point of care diagnostics for sexually transmitted
infections: perspectives and advances. Expert Rev Anti Infect Ther
2014:1–6 [Early, online].
[46] Mayaud P, Hawkes S, Mabey D. Advances in control of
sexually transmitted diseases in developing countries. Lancet
1998;351(Suppl III):29–32.
[47] Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Weeling R,
et al. Reproductive-tract infections in women in low-income, low-
prevalence situations: assessment of syndromic management in
Matlab, Bangladesh. Lancet 1999;354:1776–81.
[48] Younis N, Khattab H, Zurayak H, et al. A community study of
gynecological and related morbidities in rural Egypt. Stud Fam Plann
1993;24(3):175–86.
[49] García PJ, Carcamo CP, Garnett GP, Campos PE, Holmes KK. Improved
STD syndrome management by a network of clinicians and pharmacy
workers in Peru: the PREVEN Network. PLoS One 2012;7(10):e47750,
http://dx.doi.org/10.1371/journal.pone.0047750. Epub 2012 Oct 17.
[50] Bulut A, Yolsal N, Filippi V, Graham W. In search of truth: comparing
alternative sources of information on reproductive tract infection.
Reprod Health Matters 1995;3(6):31–9.
[51] Cohen M, McCauley M, et al. Prevention of HIV-1 infection with early
anti-retroviral therapy. N Engl J Med 2011;365:493–505.
[52] Low N, Bender N, Nartey L, Shang A, Stephenson JM. Effectiveness
of chlamydia screening: systematic review. Int J Epidemiol 2008:1–4.
[53] Giertz G, Kallings I, Nordenvall M, Fuchs T. A prospective study of
Chlamydia trachomatis infection following legal abortion. Acta Obstet
Gynecol Scand 1987;66:107–9.
[54] US Preventive Services Task Force. Recommendations for gonorrhea
screening. Accessed at http://www.uspreventiveservicestaskforce.org/
uspstf05/gonorrhea/gonrs.htm [on May 21, 2013].
[55] US Preventive Services Task Force. Screening for chlamydial
infection. Downloaded t http://www.uspreventiveservicestaskforce.
org/uspstf/uspschlm.htm [on March 12, 2014].
S31
[56] Low N, Cassell JA, Spencer B, et al. Chlamydia control activities in
Europe: cross-sectional survey. Eur J Pub Health 2011.
[57] Hansdotter F, Blaxhult A. “Chlamydia Monday” in Sweden. Euro
Surveill 2008;13(38).
[58] Hawkes S, Matin N, Broutet N, Low N. Effectiveness of interventions
to improve screening for syphilis in pregnancy: a systematic review
and meta-analysis. Lancet Infect Dis 2011;11:684–91.
[59] UNAIDS. Global plan towards the elimination of new HIV infections
among children by 2015 and keeping their mothers alive. Geneva:
UNAIDS; 2011.
[60] Potter D, Goldenberg RL, Chao A, et al. Do targeted HIV programs
improve overall care for pregnant women? Antenatal syphilis
management in Zambia before and after implementation of prevention
of mother-to-child HIV transmission programs. J Acquir Immune
Defic Syndr 2008;47:79–85.
[61] Interagency Task Team on the Prevention of HIV in Pregnant Women,
Mothers, and their Children. Preventing HIV and unintended
pregnancies: strategic framework; 2012 [London].
[62] Germain A, Dixon-Mueller R, Sen G. Back to basics: HIV/AIDS
belongs with sexual and reproductive health. Bull World Health Organ
2009;87(11):840–5.
[63] 26th Meeting of the UNAIDS Programme Coordinating Board,
Geneva, Switzerland, 22-24 June 2010Thematic segment: sexual and
reproductive health (SRH) services with HIV interventions in practice;
2013. [Available from,http://www.srhhivlinkages.org/content/
uploads/docs/articles/26thpcbthematicbackground_2010_en.pdf on
July 2013].
[64] Commission on Population. The contribution of the Programme of
Action of the International Conference on Population and Develop-
ment to the internationally agreed development goals, including the
Millennium Development Goals. New York: United Nations; 2009.
[paragraphs 20].
[65] Church K, Mayhew SH. Integration of STI and HIV prevention, care,
and treatment into family planning services: a review of the literature.
Stud Fam Plann 2009;40(3):171–86.
[66] Kennedy CE, Spaulding AB, Brickley DB, Almers L, Mirjahangir J,
Packel L, et al. Linking sexual and reproductive health and HIV
interventions: a systematic review. J Int AIDS Soc 2010;13:26.
[67] WHO. Prevention and treatment of HIV and other sexually
transmitted infections for sex workers in low- and middle
income countries: recommendations for a public health approach.
Available from http://www.who.int/hiv/pub/guidelines/sex_worker/en
2012 [on July 21, 2013].
[68] WHO. Prevention and treatment of HIV and other sexually transmitted
infections for men who have sex with men and transgender people:
recommendations for a public health approach. Available from, http://
www.who.int/hiv/pub/guidelines/msm_guidelines2011/en 2011
[on July 21, 2013].
[69] WHO, UNODC, UNAIDS. Technical guide for countries to set targets
for universal access to HIV prevention, treatment and care for
injecting drug users: 2012 revision. Available from, http://www.who.
int/hiv/pub/idu/targets_universal_access/en/index.html [on July
21, 2013].